It is a great pleasure and privilege for me to attend the 29th annual meeting of The Japanese Association for The Surgery of Trauma, in Hokkaido. This is truly the most beautiful place to be in, especially at this time of year.My talk is about the current status of trauma care system in Korea.

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Until the early 90’s, there were no emergency medicine specialists in Korea. After I served as president of the Korean Society of Traumatology from 2003 to 2005, I founded the department of emergency medicine at Seoul National University Hospital in February 2006. Furthermore, I served as president of the Korean Society of Emergency Medicine (2005-2007), and the Korean Association for Disaster and Emergency Medicine (2007-2009). I think this is why I was given the opportunity to talk about my experience in this great meeting.

Let’s move on the main topic.

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#2. This slide shows preventable death rate in Korea. Blue bar is prehospitalpreventable death rate, purple bar is hospital preventable death rate, and red bar is total preventable death rate, that is prehospital + hospital death reate. As you can see, Preventable death rate was 50.4% in 1998. It was so high compared with those of the developed countries, such as US or European countries which is 10 to 20%. Fortunatelly, the preventable death rate has gradually decreased, and it was 32.6% in 2008. The decrease of the preventable death rate was due to the introduction of National EMS fund which was made for the improvement of emergency medical service system. However, after then, the preventable death rate has slightly increased again to 35.2% in 2011. The main cause of the increase in the preventable death rate was lack of trauma care system and trauma center in Korean.

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#3. Problems in trauma care system in Korean can be categorized as follows:prehospital, hospital and fragmentation problems.

Prehospital problems were shortage of dedicated EMS personnel such as paramedics, absence of training programs for paramedic and air medical physicians, and insufficient helicopter transport system. Hospital problems were lack of Level 1 trauma center and manpowers including dedicated trauma surgeons, and insufficient government financial and legal support. Fragmentation is another problem which means lack of coordination between EMS and trauma service providers.

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#4. To solve these problems, we need to have pre-planned trauma care delivery system.A trauma care system has many components such as injury prevention,standardized EMS protocol, ER resuscitation, OR, ICU and rehabilitation, which require a multidisciplinary team approach. Trauma data collection and analysis are also needed for the trauma system performance improvement.

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#5. What is the direction of trauma care system in Korea? It should develop 1. Prehospital trauma management & transpor t2. Designaton & operation of trauma centers3. Training of dedicated manpowers4. Government financial & legal support

From now, I wil l briefly introduce the current status of Korean trauma care system.

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#6. First, I will talk about our effort to improve Prehospital trauma care and transport system

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#7. Surprisingly In 2005, a famous research institute reported very low appropriateness of prehospital intervention for the emergency conditions. As you can see, in cardiac arrest, there was no appropriate intervention for the victim. Among 80 hypoglycemic patients, there was no case who glucose was infused. This result gave a shock to all Korea EMS system as well as fire department which is responsible for the prehospital care.

#8. In 2005, Ministry of Health and welfare decided to establish the EMT-B training program for the quality improvement at the scene. 20 regional emergency centers were assigned as a EMT training centers in 2006. Eligible EMTs have been trained in the ED for 9 weeks. Emergency physicians should teach EMTs on prehospital assessment and intervention such as PHTLS, Shock management, and Field triage.

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#9. We also developed EMS protocols such standadized dispatch protocol, field triage protocol and medical direction.

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#10. Doctor Heli was introduced by the Ministry of Health and Welfare in Sep. 2011. At first, 2 doctor heli were operated at Mokpo and Incheon area to transport emergency patients at numerous islands. After July 2013, another two doctor heli were operated at Wonju and Andong. Round flight time is usually within 60min, and flight distance within 100 km. Until May this year, there were 1353 flight transports.

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#11. In addition to Doctor Heli, we have 27 EMS helicopters which are operated by 119 fire department. Red dots show the distribution of HEMS. At present, 270 personnel are working at 119 HEMS.The number of HEMS transport has been gradually increased from 2700 in 2012 to 3200 in 2013.

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#12. Next, I will talk about trauma center.

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#13. What is ideal trauma center?I think that Ideal trauma center should be rapid, organized, coordinated, and accountable

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#14. In May 2012, EMS law was revised. It contains the designation of trauma centers. Regional trauma centers should be designated by minister of Health and Welfare, and Local trauma centers should be designated by governor of city or province. Revised EMS law also states dedicated medical staffs, facilities, equipments, and financial and administrative support from central and local government.

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#15. The Ministry of Health & Welfare has planned to develop trauma system until 2016. In this plan, 2 exclusive (it means independent) trauma centers and 15 inclusive trauma centers. Among 15 inclusive trauma centers, 5 trauma centers will be more bigger than other 10 centers. In addition, the ministry of National defense are planning to set up the inclusive type trauma center in military hospital (Korean Armed Forces Capital Hospital) which is located near Seoul.

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#16. Two exclusive type regional trauma center will open at Pusan and Seoul in 2015 and 2018, respectively. These centers have more than 50 ICU beds and 200 admission ward beds.During last 2 years, 9 Inclusive type regional trauma centers were designated. 5 in 2012, 4 in 2013, respectively.Another 6 regional center will be designated until 2015. Until now, 3 trauma center were opened. Each inclusive type regional trauma centers receives financial support from government. ($8,000,000 for facility support , and $2,700,000 for annual manpower support, respectively)

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#17. This slide shows the difference between exclusive and inclusive type regional trauma centers. And at least, half of medical doctors should be certified trauma surgeons.

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#19. This slide shows example of regional trauma centers which already opened.

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#20.

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#21

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#22

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#24.

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#26. Previously, when trauma pts was brought to hospital, initially intern or EM resident saw the patient, and reported to EM physician or residents in a related department. EM physician or related residents then, reported to staffs in a related department, who finally decided treatment plan. In this process, treatment plan was delayed. In contrast, when trauma team see the trauma patient, decision of treatment plan should be done rapidly within golden hour.

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# 27. The ministry of Health and Welfare released guidelines for trauma team at regional trauma centers.Trauma team is usually composed of GS, TS, OS, and NS.Primary trauma team should be present in-hospital to meet all trauma patients in the trauma resuscitation area at the time of the trauma patient's arrival. Primary trauma team should not perform no elective surgery or procedures, during the on-call period. When primary trauma team takes a trauma patient, backup trauma team shall become the primary trauma team and shall arrive promptly when summoned.Support team is usually composed of EM, Anes, radiology, and so on. They also should be available within 30 min when called.

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#28.

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#29.

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#30. In 2008, the Korean Society of Traumatology planned to introduce certified Board System of Trauma Surgeon. So, it made draft for training program of trauma surgeon. The agreement by related societies including GS, OS, NS, TS, EM, and Urology and the accreditation from the Korean Academy of Medical Sciences were done. At last, In Dec. 2010, 1st certified board of trauma surgeons were produced. In Feb. 2011, 22 training hospitals for trauma surgeon were designated by the Korean Society of Traumatology. Now, The number of training hospital is increased to 35. Each training hospital should be evaluated every year for designation.

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#31. This slide shows the distribution of certified board of trauma surgeons according to the clinical department. As you can see, most of trauma surgeons are GS and TS.Until now, 171 trauma surgeons have been produced.85 1st and 48 2nd certified board of trauma surgeons were produced in 2010 and 2011, respectively. They were produced only by Document screening & oral test without written examination because there was no training program for trauma surgeon until 2010.

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#32. Training program is composed of Essential skill & Recommended skill part program. Essential skills should be done by all trauma surgeons.

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#33. Applicants who become to be trauma surgeon should have certified board in GS, TS, OS, NS, URO, PS, ENT and Oph. and finish 2 years of fellowship program. Two years of fellows program is composed of 22months of obligation course and 2 months of elective course, respectively. In obligation course, trauma surgeons should do for 6 months in-depth training in SICU, 10 months at one’s department, and 6 months at other departments (among GS, TS, OS, NS). Elective course can be done at other hospital including oversea training.

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#34. Another fellowship program is supported financially by EMS fund. This program was introduced in 2011 by the Ministry of Health & Welfare. About 70,000$/year is supported from Nation EMS fund for 2 years. As obligation, however, certified trauma surgeons should work at the designated trauma centers for 2 years after the acquisition of certified board.

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This is a textbook of KTAT

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This is pictures of 1st ATOM which was held at Pusan National University Yangsan Hospital last year.

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#37. 1st version of Korean Trauma Data Bank was developed by National Emergency Medical Center and the Korean Society of Traumatology, and completed on the end of Feb. 2013. At present 10 regional trauma centers are submitting data to KTDB, and all trauma centers will submitting data until 2017.

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#38. This is a part of KTDB. Type of injury, mechanism of injury, Intention of injury, vital sign, Response on arrival in ED, and so on should be input in trauma registry.

#39. GCS (eye opening , verbal, and motor response), RTS, AIS at discharge, ISS, Glasgow outcome score at discharge also be input.

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#40. Now, 10 regional trauma center are submitting data to KTDB. As you can see, data submission rates are different among trauma centers. Especially, 4 trauma centers which were designated last year show low data submission rate. To improve the data submission rate and quality of KTDB, we need dedicated personnel and education.

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#41. Until now, the preventable death rate in Korea is 35.2%. However, through our effort to improve trauma care system, the preventable death rate will go down below 20% in the near future.

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#. The mission of Trauma care system can be summarized as 3 R, right person, right time and right place. Right person means that severity of trauma patients should be assessed by field triage protocol. Right time means that severe trauma patient should be transported to trauma center rapidly (usually within 1 hr). Right place means that trauma patient should be transported to the different level of trauma center for human resources and facilities, that is, severe trauma patient should be transported to level 1 trauma center. In conclusion, desirable trauma care system should be coordinated, regionalized, and accountable.

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